title: Sinking skin flap syndrome with delayed dysautonomic syndrome-An atypical presentation.
abstract: BACKGROUND
  Sinking skin flap syndrome or "syndrome of the trephined" is a rare complication after a large craniectomy, with a sunken skin above the bone defect with neurological symptoms such as severe headache, mental changes, focal deficits, or seizures.
  
  
  METHODS
  We report a case of 21 years old man with trefinated syndrome showing delayed dysautonomic changes.
  
  
  CONCLUSIONS
  Our patient had a large bone flap defect and a VP shunt that constitute risk factors to develop this syndrome. Also, there is reabsorption of bone tissue while it is placed in subcutaneous tissue. The principal symptoms of sinking skin flap syndrome are severe headache, mental changes, focal deficits, or seizures. Our patient presented with a delayed dysautonomic syndrome, with signs and symptoms very characteristics. Only few cases of this syndrome were related in literature and none were presented with dysautonomic syndrome.
  
  
  CONCLUSIONS
  We reported here a very uncommon case of sinking skill flap syndrome that causes a severe dysautonomic syndrome and worsening the patient condition.
authors.affiliation: Division of Neurosurgery, Botucatu Medical School, São Paulo State University, UNESP, Botucatu, Brazil; Hospital das Clínicas, UNESP, Botucatu, Brazil. Electronic address: frromero@ig.com.br.
authors.forename: Flávio Ramalho
authors.initials: FR
authors.lastname: Romero
authors.forename: Marco Antônio
authors.initials: MA
authors.lastname: Zanini
authors.forename: Luis Gustavo
authors.initials: LG
authors.lastname: Ducati
authors.forename: Roberto Colichio
authors.initials: RC
authors.lastname: Gabarra
keywords: Dysautonomic syndrome; Sinking skin flap syndrome; Trefinated